Fascia in Primary Care Series
~Benign Positional Paroxysmal Vertigo (BPPV) or Vertigo, is both a simple and difficult medical condition. We are taught in medical school how to triage different types of Vertigo — the minority that merits serious evaluation, e.g., due to a stroke or brain tumor, and the “benign” kind, the most common form. While “benign” means that it is non-life-threatening, the term underestimates the loss of quality of life and freedom to travel to which recurrent sufferers are sentenced.
While serious causes of Vertigo exist, 90% of vertigo is of the BPPV type. In short, it occurs briefly (seconds) with certain positions or movements. Since no cause is known, it is called an idiopathic condition.
The inner ear is where our balance-sensing organ, the three semicircular canals, resides. As we move our head, the liquid inside these canals senses this change and sends signals to the brain to interpret where we are in space. This is similar to how we feel our bodies pressing to one side of a car during a turn. Feeling the change in force, we deduce in which direction we are moving, even with closed eyes. For BPPV, it is taught that tiny crystals or “otoliths” wander into the semicircular canals and get stuck there and interfere with the purity of data being sent to the brain. Confused by the conflicting input, the brain “creates” the sensation of Vertigo. Some treatments target this information discrepancy and help the brain ignore aberrant signals.
Medications for BPPV aim for symptom relief via dimming the nervous system. Because of marked drowsy side effects, patients often forego the pills and stay in bed until the condition improves. There is no cure, only symptom management.
Based on the otolith theory, several maneuvers aim to dislodge these “rogue crystals” through a series of head-body movements, the most well-known of which is the Epley maneuver. It is not for the faint-hearted, as it can provoke severe dizziness and nausea. While a clinician’s experience cultivates speedy diagnosis of BPPV, the career count of patients who miss work and life events from prolonged or recurrent vertigo episodes humbles the ego.
Mrs. G, a Primary Care patient of mine, was a petite woman who came to Urgent Care when I happened to be working. With a slight build and medium brown short hair, she was retired and had the mild-mannered demeanor of someone who is used to following company policies. She had been suffering from severe Vertigo for several days. Since she had recently completed treatment for brain metastases from breast cancer, I carefully verified that she had BPPV. She was a good candidate for my new approach to Vertigo.
I had already discovered that many musculoskeletal complaints could be relieved by myofascial manipulation. Based on personal experience and successes with patients, I began making correlations that had never occurred to me in my career.
Fascia is a strong sheath of connective tissue that surrounds individual muscles and tendons as well as internal organs. As much as 30% of muscle strength is attributed to the fascia, creating a complex matrix of tensional lines in the body. As it unifies a network of muscles, fascia provides more strength and elasticity than any solo musculoskeletal unit.
Myofascial researchers and bodyworkers (fasciaresearchsociety.org) have discovered that freeing fascia can decrease tension forces and thus improve mobility as well as organ function. Fascia previously had been discarded as an obstacle to the “real” anatomy of the human body in dissection. Its lack of discrete geography made it difficult to study, and thus, it escaped notice by all but the most insightful of observers for decades. Fascia’s universality lends support to acupuncture’s ancient concept of body meridians and mapping of external needle sites to internal organs.
With this broadened perspective, when I examined patients with ear pain and a normal ear canal, I began to notice that a neck muscle near the symptomatic ear usually looked tense and prominent. I experimented with manual release of this hypertonic muscle and found that it could resolve the ear pain immediately. I began doing this regularly for adults and pediatric patients when the physical exam did not reveal any other cause of pain.
How many other cases of ear pain over my career had been from a tight neck muscle, I wondered.
One day, I noticed that this same neck muscle, the sternocleidomastoid (SCM), had the same appearance on a patient with BPPV. When I released that muscle at the clavicle (also known as collarbone) and sternum, the dizziness improved immediately. In one case, the patient was having active nystagmus (rapid, short, repetitive eye movements) which stopped abruptly with SCM muscle release.
It occurred to me that other Vertigo treatment maneuvers involve a lot of neck movement. Perhaps the SCM muscle tension was the common factor in the treatment result and not the jostling of crystals in the semicircular canals.
The SCM muscle is named for its origin at the sternum and clavicle (sternocleido) and insertion at the mastoid bone behind the ear. “Vampire bites” are often illustrated on this prominent diagonal muscle. The most basic functions of the SCM muscle are to flex the neck forward (looking down at your cell phone), to the side (pondering head gesture), and to turn the head (checking blind spots as you change lanes). As the left SCM muscle contracts, it shortens and pulls the left mastoid towards the origin and thus the head rotates to the right. Our fascia encases and superglues the muscles to prevent them from shearing off of the bones when force is generated.
With age, injury, or inflammation, our fascia can become stiffer and adherent, restricting movement to the point of causing dysfunction. Myofascial bodywork, such as Fascial Manipulation®, Structural Integration®, osteopathic manipulation, Cranial-Sacral Therapy® or Active Release Therapy®, liberate fascia, and muscles to restore flexibility and function.
The SCM muscle attaches to the mastoid, near where cranial nerve VII (CN VII), the facial nerve, exits the skull. Tracing the path of the nerve backward reveals that it shares space for a short distance with CN VIII, the vestibulocochlear nerve, within the Internal Auditory Canal (IAC). Tumors within the IAC can result in symptoms related to impaired taste, salivary gland flow, facial muscle function, hearing, and balance.
What if BPPV was not caused by renegade otoliths afloat in the semicircular canals, but by fascia, fascial tension transmitted to a nerve, disrupting its normal function?
I offered to release Mrs. G’s SCM muscle to help stop her Vertigo. Since I had helped her in the past with her chronic abdominal pain, she was open to trying soft tissue manipulation. I proceeded to mobilize the origin of her SCM while she slowly rotated her head. Afterward, she was able to comfortably move her head without dizziness. It seemed to work. But just as I helped her sit up, her Vertigo returned and she clutched me to stabilize herself until the sensation passed, several seconds.
I was puzzled. My theory was that the fascial tension of the SCM muscle was putting traction on CN VIII via CN VII. Releasing the SCM muscle had worked, but somehow transitioning to a seated position had reactivated the tension. I helped her lie down again. The next Urgent Care patient would have to wait.
Since chest and abdominal muscles contract to sit up, I reasoned, perhaps this tension traveled all the way up to her SCM muscle again. I decided to check the fascia immediately continuous with the SCM muscle, and discovered tight, dense fascia in a band down to her mid-sternum. With the release of this fascia, Mrs. G was able to sit up and walk comfortably without any dizziness!
Still, I needed to understand what had provoked Mrs. G’s vertigo — the treatment was not effective if her Vertigo returned after lying down once she was at home.
Several years prior, Mrs. G had had radiation therapy for her breast cancer, a treatment known to scar and stiffen nearby soft tissue. During the last few months, she had been resting more, likely due to her brain metastases, watching TV for a few hours every evening. The TV was at the foot of her bed, and she had reclined, propped up with pillows behind her back. Simulation of the scenario revealed the tension created in her SCM muscle and chest when reclining without any head support; in addition, she had to flex her neck downwards to see the TV screen. I hypothesized that with decreased elasticity of her chest fascia, tension was easily transmitted from abdominals via her chest, up to her SCM muscle.
With grateful stability, Mrs. G walked out of Urgent Care with a prescription, not for medication, but for how to watch TV — either sitting fully upright in a chair or in bed with pillows for head support and the TV on a higher table. When I saw her again many months later, she reported that the Vertigo had never returned. ~